Sunday, February 04, 2007

Action items In some context of your own choosing, take some action today to promote the passage of a law in your state or country that will mandate that all girls get vaccinated for Human Papillomavirus (HPV). However, make sure that the actions taken respect the principle of a proper separation of powers that is necessary to protect the people from a tyrannical executive branch.

The Case of Texas

Rick Perry, the governor of Texas, has signed an executive order mandating that all girls in Texas get a vaccine for Human Papillomavirus (HPV), a major cause of cervical cancer.

I have one serious problem with this executive order – this is with a member of the Executive Branch of government taking legislative authority away from the legislature. As I have argued repeatedly with regard to President Bush’s signing statements, there is good reason for a system of checks and balances – too much power in too few hands is a recipe for disaster. This means leaving it to the legislature to make law.

I have no objection to the legislation itself, and I would certainly encourage any state to pass this legislation. The claim that this vaccine promotes promiscuity is an absurdity. The argument used against vaccinating children is as foolish as an argument prohibiting motorcycle drivers from wearing helmets, or prohibiting seat belts or air bags or child safety seats in automobiles, on the grounds that the possibility of getting maimed or killed in a wreck will cause people to drive more carefully.

Principles of Parental Obligation Revisited

In an earlier post titled, “Consent and Dignity: The Case of Ashley” I argued for a principle that governs one person making decisions for another that the agent should choose what the individual he is choosing for would have chosen for herself if she was rational. In fact, a rational person would choose to get this vaccine. Even a rational person who also decided to protect herself from sexually transmitted disease through abstinence has a reason to be concerned about a possible sexual assault, an unfaithful spouse, a spouse who was not so careful when younger, or a spouse who was a victim of a sexual assault.

In addition, I argued that this principle of doing what the individual one is choosing for would have chosen for herself has to consider the fact of the other person’s incompetence. If I knew that I was prone to make irrational decisions when gambling, it would be rational of me to take precautions against the high consequences of those mistakes. I could resolve to go gambling only with a certain amount of money and no access to any more money. Children are prone to make irrational decisions. Parents, whose obligation is to choose for children what those children would choose for themselves, have an obligation to protect children from their own irrational and immature choices.

Some people protest, “We have a right to decide how to raise our children!” Not when there is good evidence that one is raising one’s child in a way that puts the child’s life and health at risk. We can ask such a person, “What would you say of the parent who thinks that his child needs daily sexual stimulation to grow up healthy. Does, he have the right to raise his child as he sees fit?” The principle behind the answer to this question is that there is reason not to allow parents to “choose” to risk causing their child clear and scientifically demonstrable harm.

For these reasons I would certainly urge any legislature to support this law. Giving a child this vaccine is something that every good parent will do. However, this is an issue for the legislative branch, not the executive branch.

An Aside on Religious Beliefs and Harm

I have read comments from many parents who say, “I know that my child will never have extra-marital sex, so I know that they will never need this vaccine.” These parents are idiots. A parent can no more know this than one can know that their child will never use drugs, smoke, or drink. Nor can any parent ever know that their child will not be the victim of a sexual assault or find a partner who was not so careful.

As an aside, it is also worthy of mention that this is yet another case where people confounded by religious beliefs adopt attitudes that put the health and even the lives of others at risk – that put the lives and health of their own children at risk. I have not complained about religious beliefs when it leads people to doing things that help others or help protect people from harm. Yet, this is another item to add to the list where religious beliefs cause those who have them to put others at risk, or at least to refuse to remove them from harm’s way.

It is a habit of those who criticize religion to point to incidents in the past – crusades, inquisitions, slavery, and the like, as reason to condemn religion. This is actually a very poor argument. Unless the person one is talking to actually endorses the crusades, inquisitions, and slavery of the past it is unreasonable and unjust to accuse him of supporting those moral crimes.

However, it is perfectly legitimate to complain that a person’s religious beliefs, if they imply opposition to this legislation, would contribute to the deaths of thousands of tens of thousands of today’s children if they were to become widespread. This is a good reason to oppose any attempt to make those beliefs widespread. Yet, even here it the argument applies only those whose religious beliefs lead to opposition against giving children this vaccine.

Moral Principles of Government Power

In the case of Texas, such a bill faced heavy opposition. There was a very good chance that the legislature would not come up with the right answer in this issue. However, we have a lot of very good reasons to reject the principle that the Executive Branch may override the Legislative Branch whenever the Executive thinks the Legislature is mistaken. The legislature has the right to be wrong.

I can fully understand the temptation on the part of the governor to take action. If I were governor, I would approach this issue by imagining myself sitting in the hospital room of a young woman with cervical cancer. I would imagine myself being forced to tell her, “You are in this situation because your parents were fools. Even though I could have forced them to make a wiser choice . . . even though you would not have been in this situation if I had done so . . . I choose to allow your parents to remain fools and to put your health, even your life at risk. I cannot deny some responsibility for this.”

Yet, every would-be tyrant ever lived would love to have a principle of government that said, “The Executive Branch may assume legislative authority whenever it thinks that the legislature is wrong.”

It is all too tempting to adopt an attitude that says, “The Executive Branch is limited in its power whenever it, like the Bush Administration, is prone to do things that I do not like; and far less limited in its power when it does something I like.” However, this is not a viable principle to adopt. No doubt, the Executive Branch is not going to appeal to me to determine how much power it has. If it is given these overly broad powers, then it will use them whenever the Executive pleases to do so, not when it pleases me.

Adopting a narrower principle requires that I allow that there will be cases when the Executive Branch oversteps its boundaries even when they are doing something that I very much would like to see done, over the protests of a legislature who are opposed.

It is far more important, capable of saving society from far greater harms (as the Bush Administration’s abuse of this principle has proved), that the Executive Branch not be allowed to take for itself the power to pass legislation.

Education and Action

This is not to say that nothing should be done to protect those children from foolish parents. Instead, it argues for a strong campaign to educate the people to create a legislature that will pass this legislation. This campaign does not need to convince everybody, just enough people to actually get the bill passed.

This type of education campaign will actually be good for a society because it should lead to a better educated population. The Governor’s attempt to bypass the legislature not only forces this decision on a population whose representatives do not approve it, it also keeps the population in the dark as to the merits of this legislation. It is one thing to force an individual to perform some action. It is another to educate that person about the reasons why he should perform that action.

Those citizens who do not take steps to educate the population about the moral requirement to get the Legislature to approve this legislation, those are the citizens who should imagine themselves sitting at the bed of some future young woman telling her, “I could have saved you from this, but I did nothing.”

5 comments:

As a Texan, I agree completely with both your points. If I had a daughter, I would have her vaccinated. I think any parent that wouldn't is guilty of neglect.

Also, I agree that Governor Perry should let the state legistature make this call. The only exception would be if the legislature has already vested the executive with the power to enforce vaccinations. I don't know if this is the case, but it's a possibility.

I'm surprised that Perry did this. He is very religious, and this seems to fly in the face of the opinion of most christians on this subject.

BTW, I've met Perry, and while he seems very nice, I'd really prefer that he stop signing legislation in churches.

1. GARDASIL is a vaccine for 4 strains of the human papillomavirus (HPV), two strains that are strongly associated (and probably cause) genital warts and two strains that are typically associated (and may cause) cervical cancer. About 90% of people with genital warts show exposure to one of the two HPV strains strongly suspected to cause genital warts. About 70% of women with cervical cancer show exposure to one of the other two HPV strains that the vaccine is designed to confer resistance to.

2. HPV is a sexually communicable (not an infectious) virus. When you consider all strains of HPV, over 70% of sexually active males and females have been exposed. A condom helps a lot (70% less likely to get it), but has not been shown to stop transmission in all cases (only one study of 82 college girls who self-reported about condom use has been done). For the vast majority of women, exposure to HPV strains (even the four "bad ones" protected for in GARDASIL) results in no known health complications of any kind.

3. Cervical cancer is not a deadly nor prevalent cancer in the US or any other first world nation. Cervical cancer rates have declined sharply over the last 30 years and are still declining. Cervical cancer accounts for less than 1% of of all female cancer cases and deaths in the US. Cervical cancer is typically very treatable and the prognosis for a healthy outcome is good. The typical exceptions to this case are old women, women who are already unhealthy and women who don't get pap smears until after the cancer has existed for many years.

4. Merck's clinical studies for GARDASIL were problematic in several ways. Only 20,541 women were used (half got the "placebo") and their health was followed up for only four years at maximum and typically 1-3 years only. More critically, only 1,121 of these subjects were less than 16. The younger subjects were only followed up for a maximum of 18 months. Furthermore, less than 10% of these subjects received true placebo injections. The others were given injections containing an aluminum salt adjuvant (vaccine enhancer) that is also a component of GARDASIL. This is scientifically preposterous, especially when you consider that similar alum adjuvants are suspected to be responsible for Gulf War disease and other possible vaccination related complications.

5. Both the "placebo" groups and the vaccination groups reported a myriad of short term and medium term health problems over the course of their evaluations. The majority of both groups reported minor health complications near the injection site or near the time of the injection. Among the vaccination group, reports of such complications were slightly higher. The small sample that was given a real placebo reported far fewer complications -- as in less than half. Furthermore, most if not all longer term complications were written off as not being potentially vaccine caused for all subjects.

6. Because the pool of test subjects was so small and the rates of cervical cancer are so low, NOT A SINGLE CONTROL SUBJECT ACTUALLY CONTRACTED CERVICAL CANCER IN ANY WAY, SHAPE OR FORM -- MUCH LESS DIED OF IT. Instead, this vaccine's supposed efficacy is based on the fact that the vaccinated group ended up with far fewer cases (5 vs. about 200) of genital warts and "precancerous lesions" (dysplasias) than the alum injected "control" subjects.

7. Because the tests included just four years of follow up at most, the long term effects and efficacy of this vaccine are completely unknown for anyone. All but the shortest term effects are completely unknown for little girls. Considering the tiny size of youngster study, the data about the shortest terms side effects for girls are also dubious.

8. GARDASIL is the most expensive vaccine ever marketed. It requires three vaccinations at $120 a pop for a total price tag of $360. It is expected to be Merck's biggest cash cow of this and the next decade.

These are simply the facts of the situation as presented by Merck and the FDA.

For a more complete discussion on GARDASIL with sources, click on my name.

I can fully understand the temptation on the part of the governor to take action. If I were governor, I would approach this issue by imagining myself sitting in the hospital room of a young woman with cervical cancer. I would imagine myself being forced to tell her, “You are in this situation because your parents were fools. Even though I could have forced them to make a wiser choice... even though you would not have been in this situation if I had done so... I choose to allow your parents to remain fools and to put your health, even your life at risk. I cannot deny some responsibility for this....”Those citizens who do not take steps to educate the population about the moral requirement to get the Legislature to approve this legislation, those are the citizens who should imagine themselves sitting at the bed of some future young woman telling her, “I could have saved you from this, but I did nothing.”

Actually, that's not quite a correct analysis of the decision as enacted. Because there is an opt-out option for parents who object, the decider (whether Governor or citizen) could still end up having the same conversation with a woman with cancer. It would merely be less likely or frequent with the executive decision in force.

Lacking a degree in medicine and the time to do detailed research on every subject, I adopt the rule of following the recommendations of people who do have degrees of medicine and who research these issues full time.

The Centers for Disease Control (and the unanimous recommendation of its Advisory Committee on Immunization Practices), the American Cancer Society, the Mayo Clinic, all recommend the vaccine.

As for the costs, the Governor's resolution call for state agencies to cover the costs for those who cannot afford it (as is the case with other childhood vaccinations).

It is my experience that when non-experts raise objections to scientific findings that have the near unanimous consent of experts, they cherry-pick and distort the data to support their conclusion.

For example, Stickdog's Item #5 was covered in the Mayo Clinic recommendation as, "The cervical cancer vaccine has proved to be remarkably safe. The most common complaint is soreness at the injection site, the upper arm. Low-grade fever or flu-like symptoms also are common. But the effects are usually mild. No one in the clinical trials discontinued the vaccination series because of side effects."

The fact that MERCK will profit from the vaccine is irrelevant - an example of ad hominem circumstancial fallacy - that is, "Your conclusion is false because you will benefit if I were to believe it."

I do not think that is it right to try to force this on people, or to convince governments through huge lobbying efforts and advertisements.

I agree with your comment about the logcal fallacy, but I it is still relevant, especially if Merck expanded their operations on the expectation on the sale of the vaccine.

Merck has a big stake in this being successful, so I would assign a large value to the small voices out there trying to address health risks. I have seen enough examples of profit winning over what most of us would consider ethical behavior, to not look into that possibility.

Like you said, we do not have the time or knowledge to research this ourselves, so we rely on experts. How many times have the experts approved drugs only to later reject them due to dangerous side effects that came out after time?

I believe it is too early to decide that every 11 year old girl should get this vaccine. It should be available to those who decide that the possible risks of the vaccine outweigh the risks of infection. Is that reasonable?

About Me

When I was in high school, I decided that I wanted to leave the world better off than it would have been if I had not existed. This started a quest, through 12 years of college and on to today, to try to discover what a "better" world consists of. I have written a book describing that journey that you can find on my website. In this blog, I will keep track of the issues I have confronted since then.